An investigation of endotracheal intubation and alternative intubation devices for use by paramedics in out-of-hospital care

For patients in cardiac arrest, early chest compressions and adequate airway management to ventilate and oxygenate patients’ lungs is essential and can be achieved through endotracheal intubation (ETI). This said, there is debate around whether ETI is required during cardiac arrest (CA) management with arguments for and against whether CA outcomes are improved when ETI takes place. There is further debate as to whether paramedics should carry this skill out in practice, corresponding to the effectiveness of ETI attempts in the out-of-hospital environment. There are several complications associated with ETI and alternative intubation devices (AIDs) are available to help overcome a number of these, though are not currently used in paramedic practice. There is a limited amount of current research that studies the use of AIDs in paramedic practice. This thesis aimed to explore current out-of-hospital practice in relation to airway management and ETI and critically examine and compare the use of AIDs by paramedics. A three-stage approach was undertaken. A retrospective case note review established current airway management practices in one area of the UK, over the period of a year. An online survey sought paramedics’ opinions on airway management and ETI. Finally, a prospective, experimental study compared four AIDs (a video-optic, standard blade laryngoscope (SBL), retroglottic tube and intubating laryngeal mask airway), through observed intubation attempts by paramedics using each device. Preference ranking and comments provided reflections on the practical application of the devices. The research project has shown that a range of airways are used in the out-of-hospital care environment, with varying success rates. ETI was attempted on less than half of 2,779 patients in cardiac arrest, with a 77% success rate. Opinion survey findings indicated that 79% of 181 paramedics would commonly perform ETI on a patient in cardiac arrest. In the same sample, 83% believed ETI to be gold standard airway management. On examination and comparison of four AIDs, no one device proved to be more successful than another when used by paramedics. The Airtraq, SBL and Combitube were equally successful, with success rates of over 97%. In comparison the iLMA was least successful, with a 65% success rate (p≤0.001). No statistically significant differences were identified between the devices in terms of number of attempts needed for successful intubation. Time to intubate with the devices was between 42 seconds (MBL) and 86 seconds (iLMA), with statistically significant differences between the iLMA and all the other devices. Paramedic participants preferred the video-optic device, which was attributed to the good view of the vocal cords the device provided, alongside the ease of use. Further research on ETI and the use of AIDs by paramedics in clinical practice is required, as this was a mannikin study carried out in a controlled environment. Recommendations for a comprehensive training programme and predetermined skill maintenance plan when introducing any new device into practice, are suggested.